Geographical Spread – 6HB and Voluntary/Private Sector PartnersRange of City Town Community and Rural PP -institutional / non-institutional placementsPartnership arrangements UWS MoU/School PP Partnership Agreements/Access arrangements for students 1200 placement learning experiences across 6 Health Boards/Independent/Private Sector 2500 pre-registration students accessing learning environments 5908 mentors within placements and 42 Practice Education Facilitators/Care Home Education Facilitators (to support mentors and learning environments)
There is no gold standard for assessing sufficiency of the healthcare workforceEstimates of numbers / density refer to active health workforceData is derived from multiple sources – national population censuses, labour force and employment surveys, health facility assessments and routine administration systems (registries on public expenditure, staffing and payroll as well as professional training, registration and licensure) Diversity of sources gives considerable validity in the coverage and quality of data – not clear whether both public and private sectors are included
1. Health Links Forum Meeting 5 7th February 2013
2. Health Links Forum Meeting 5 7th February 20132.15pm: Welcome2.20pm: Joyce Banda video2.25pm: TED Blog2.40pm: Scotland-Malawi maternal health links Part 13.15pm: Tea and coffee break3.30pm: Scotland-Malawi maternal health links Part 24.00pm: Discussion groups: Addressing the challenges and finding solutions4.45pm Brief plenary4.55pm The way forwards5.00pm Close
3. Health Links Forum Meeting 5 7th February 2013http://www.nyasatimes.com/malawi/2013/01/11/joyce-banda-discusses-safe-motherhood-in- malawi/
4. St Andrews-Malawi Partnership
5. 1st SGIDF-funded project.• Partnership between the Medical School at St Andrews and the only medical school in Malawi, the College of Medicine.• St Andrews collaborated with College of Medicine (COM) to assist the College with a major review of the undergraduate medical curriculum.• The changes were identified and driven by the need to modernize the curriculum content and its delivery, and significantly increase the number of medical students in training.• As a result of two joint conferences in Blantyre, the COM implemented a new 21st century curriculum in January 2009.• The COM has now reached the point of admitting 100 medical students per year up from 40-50 before this project started.
6. 2nd SGIDF-funded project.• We will extend the curriculum review to the Allied Health Sciences programmes in the COM.• Extend the curriculum review to the Diploma for Clinical Medicine in the COHS in Lilongwe, liaising with other projects pertaining to the clinical training of these students• Development of an Honours B.Sc. in Biomedical Science at COM to give a new science degree programme• Working with the library at the COM to improve the efficiency in resource utilisation.• Encourage the existing partnerships between Malawian undergraduates and those at St Andrews.
7. 2nd SGIDF-Funded Grant• Work with the Department of Community Health to develop a postgraduate Masters in Global Health at the COM.• Extend current IT and LT support available to other local degree programmes and out to other campuses.• The LT team will work with the Malawian systems developers to consolidate and extend the online curriculum management system currently used by the COM to all its programmes.• Purchase of 50 PCs and monitors for Lilongwe computer classroom. Purchase of desktop PC software licences for each. 8
8. Health Links Forum Meeting 5 7th February 2013
9. School of Health,Nursing & MidwiferyThe Development of a Multi-Professional Skills Lab in Blantyre Malawi
10. Campus Locations Paisley Campus Ayr Campus Dumfries Campus Hamilton Campus N
11. Four Campus Equity
12. Alison Mc Lachlan 12th December 2006
13. International Development Projects• Three year Grant Award Scottish Government (2006-9) 1. Educational development of acute care skills / transfer of CS technology (IDF SM9) 2. Development of a support programme for newly-qualified practitioners (IDF SM10) 3. Consultancy for 4 year BSc in Nursing / Midwifery (KCN)
14. Lilongwe – Kamuzu College of Nursingand Malawi College of Health Sciences
15. Current International Development Project• Project M53 ‘Development of a multi-professional skills lab at Blantyre Malawi’• Partners: College of Medicine Kamuzu College of Nursing Malawi College of Health Sciences• Methodology: ‘Train the Trainers’ Live Video Link -SMOTS (Scotia Medical Observation & Training System)
16. Blantyre College of MedicineMulti-Professional Skills Lab
17. Kamuzu College of NursingLeadership & Management Programme
18. Outcomes• Clinical Simulation established-4 Nursing Skills Labs across Lilongwe, Blantyre and Zomba Regions• 1 Multi-Professional Skills Lab, Blantyre - establishment of inter-professional education• Future live video link from Blanytre to Scotland –huge possibilities L & T• Enhanced curriculum design and clinical simulation embedded in curricula (pre/post graduate/CPD)
19. Thank you for listening Zikomo Kwambiri
20. Health Links Forum Meeting 5 7th February 2013
21. VSO ScotlandMaternal Health Projects in Malawi
22. THET project: Bringing together midwives andnurses to improve maternal health in Malawithrough volunteerism and partnershipsAim: The project will:Develop a strong, long term Recruit volunteer tutors andvolunteering programme that advisers to contribute to scalingtransfers skills between UK up the number of highly skilled and qualified nurses andand Malawian health midwives in Malawiprofessionals, leading to theimmediate and long term Increase recognition of value of international volunteeringimprovement in quality of amongst UK Health professionals,maternal health services for as a valuable part of theirpoor and rural women in medical career – support fromMalawi RCN, RCM in UK
23. THET activitiesVolunteers: and•21 nurse/midwifery tutors 6 HR/ Management information•2 midwives/nurses as CPD advisersfacilitators working in the Ministry of Health to•2 Malawian Diaspora nurses or improve the quality of HRmidwives Management information systems•6 Organisational DevelopmentAdvisers Project partner - the Nurses andworking in 7 nurse training Midwives Council of Malawi willinstitutions: support the CPD programmeKamuzu, St John’s, Nkhoma, StLukes, Trinity, Malamulo, Mulanje
24. Ntcheu Integrated Maternal HealthProject – Scottish Government fundedAim The project will:To improve the skills of clinical Increase the retention ofstaff – specifically midwives – to qualified nurses and midwivespromote maternal services and providing ‘on the job’ support toimprove knowledge and health the Continuous Professionalseeking behaviour of Development Facilitator and 25communities in Ntcheu (Ganya nurse/midwives across 11 healthand Njolomole Traditional facilitiesauthorities) Support Safe Motherhood Groups which raise awareness of maternal health risks and services
25. Ntcheu Integrated Maternal HealthProject, 2Volunteers: Partner agencies:Two nurse/midwife volunteers Peri-natal Care project (PNC)withinvolunteering for 2 years Ministry of Health – will co-ordinate Safe Motherhood groupsTwo Malawian Diaspora Theatre for a Change – will use popularvolunteers, volunteering for 3 theatre to promote safe motherhoodmonths Parent and Child Health initiative (PACHI) – linked with University College London Centre for International HealthVolunteers will provide ‘on the & Development – will monitor andjob’ support and structured CPD evaluate project impactactivities for local nurses and MIND – Scottish based Malawianmidwives diaspora NGO – will recruit Malawian midwives and disseminate info in Scotland
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29. Supporting Midwives in Rural AfricaA model for retention in the Malawi CMT programme
30. Project scopeAim : to strengthen and evaluate the training andsupport of midwives in rural MalawiObjectives Develop capacity for clinical teaching by providing training and teaching/learning materials Develop model of mentorship for CMTs Support review and updating of curriculum Increase health systems support for rural midwifery Embed midwives in communities Evaluate the impact of CMT programme
31. Challenges for maternal healthRetention of midwives in rural areasMentoring and supervisionContinuing professional development/career pathEnvironment of careReferralProviding acceptable care
32. Challenges for project teamCommunicationsEmploying a project officerAccessing fundsAccessing sitesDemonstrating impact
33. Health Links Forum Meeting 5 7th February 2013Tea and coffee served at the back of the hall
35. Overview• Link established 2005• Education: 43 courses including 2 train-the-trainers- ACOs from throughout Malawi• Critical care/ obstetric and paed emergencies and trauma/transport of critically ill/advanced life support/Communication(SBAR)• Sustainability: Developed Local faculty• Equipment- reconditioned “condemned”• Support from ministry- establish HDUs• New project on multi-disciplinary training in obstetric emergencies
36. Monitoring and Evaluation• Feedback from course participants• Pre- and post- course tests of knowledge• Supervision of local faculty teaching• Data from hospitals following HDU provision
37. Dedza hospital data Pre-HDU 2011Transfers to central 80% 6%( 9/148)HospitalMaternal deaths per 3-4 1-2month Balaka Hospital data Pre- HJDU 2011Maternal deaths per month 3-4 2
38. Mangochi (8,300 deliveries)-2 HDUs 4 bedded maternity and 2-bedded general HDU 2006 2011HDU admissions per 0 300annumsepsis 27 530 -i.e. x19abortion 450 650- i.e. x1.4eclampsia 48 112 – i.e. x2.3Referrals to Zomba 30% of previousCentral Hospital yearsIn-hospital annualmaternal mortality 120 60
39. Effect of Scotland Malawi Anaesthesia coursesPre- 2006 Post course• No critical care at district • Critical care provided in hospitals district-Transfer numbers• Many deaths during transfer of decreased by up to 74% unaccompanied critically ill to • Of those treated locally- central hospitals survival rate is 70-80%• Poor communication from referring hospital • Transfers are conducted safely- proper resus, personnel and communicationMaternal deaths decreased by 50% in the 3 centrescollecting data
40. Current ChallengesIn Malawi1. Essential equipment and drugs2. Per Diems3. Taxes on equipment entering the countryIn Scotland: Administration of grants- NHS act is interpreted as prohibiting accounts dept from administering grantunless the project is of direct benefit to the people of Scotland Leave from NHS departments to deliver teaching.
41. Aspirations for SMP supportWith Malawi government:1. Encourage discussion on per-diems at Malawi ministry of Health – including all NGOs2. Negotiate on taxes applicable on donations entering the countryWith Scottish Government:1. Discuss Scottish Government commitment through the NHS- specifically-Effect on Scottish waiting lists of additional leave by hospital doctors. Shouldwe include locum and “on-costs” in our grant applications1. Discuss Scottish Government position on Scottish NHS accounts departments administering grants.
42. Health Links Forum Meeting 5 7th February 2013
43. Dina McLellan7th February 2013
44. May 2005 – Scottish Franchise ALSO UK (self financed) November 2005 – Scotland signed co- operation agreement with Malawi: Contribute to the improvement of maternal health by supporting the increase in the number of trained midwives and facilitating the exchange of knowledge and skills required for dealing with obstetric and gynaecological emergencies
45. 3 year funding 2005/2008 Extended 2009/2010 Sorenson, B L., Advanced Life Support in Obstetrics (ALSO) and post- partum haemorrhage: a prospective intervention study in Tanzania., Acta Obstetricia et Gynecologica Scandinavica, Volume 90, Issue 6, Page 609- 614, June 2011 Adaptable Incorporated local needs Development of one day course BLSO
46. 1238 - 2 day ALSO 151 – one day emergency skills training / BLSO >40 instructors ALSO Malawi – Advisory Faculty BEmOC
47. Build on past success Utilise extensive instructor resource Avoid duplication of effort / conflict Ongoing co-operation and communication between MOH/RHU
48. Health Links Forum Meeting 5 7th February 2013
49. Maternal health research at IIHD Dr. B de Kok firstname.lastname@example.org Source pictures: GuardianUK, UNICEF
50. IIHD Maternal Health ProjectsProject 1. Loss in childbearing in Malawi: Howinterpretations of responsibility, blame and entitlementto care may affect maternal health care.Dr. B. de Kok, 1 year research project. Funder: ISRFProject 2. The changing role of Traditional BirthAttendants in maternal health in Malawi : Anexploration of stakeholders’ perceptionsIsa Uny, 3 year doctoral research project• Both qualitative studies, both just started.
51. Partnerships for maternal health• Malawian partners: – Centre for Social Research, Zomba. – KCN (Address Malata) – clinical officer, community member – Challenges –unknown; too early !• SMP: – Learning, avoiding duplication – Universities; critical reflection, deeper analysis of ‘nebulous’ aspects
52. Health Links Forum Meeting 5 7th February 2013
53. Screening for diabetes inpregnant women in Malawi A simple way to improve maternal and neo-natal health
54. What is gestational diabetes?
55. Gestational diabetes.• Diabetes mellitus which is detected for the first time during pregnancy.• May be undiagnosed diabetes.• May be diabetes that develops during pregnancy and then ‘disappears’ shortly after the birth of the baby. In Scotland, mother is tested 6 weeks after delivery.
56. Gestational Diabetes.• If diabetes in the mother does ‘disappear’ after the birth of the baby it is likely to be present in future pregnancies and the mother has an increased risk of developing diabetes later in life.• *Women with a history of GDM have a 60% chance of developing diabetes (usually type 2) within the subsequent 20 years and this risk is increased by obesity. For this reason they should - -- have an annual fasting glucose measurement performed.* NHS GGC Guidelines
57. Diabetes.• Pregnancy causes changes in glucose levels in the mother.• Increasing glucose levels in the mother increases supply to the fetus hence enhanced growth of the fetus.• Gestational diabetes may develop – if not controlled, mother and offspring at risk.• Type 1 and Type 2 mothers and their offspring are at similar risk if diabetes uncontrolled.
58. Risks to the fetus:• Developmental malformations• Increased insulin secretion• Accelerated growth
59. Risks to the neonate:• Reduced glucose levels in the blood of the neonate• Impaired production of lung surfactant – increases risk of respiratory distress syndrome
60. Risks to mother:• Miscarriage• Pre-eclampsia• Premature labour• Polyhydramnios
61. What should be done.• Pregnant women with diabetes should be offered dietary advice and blood glucose monitoring.• They should be treated with glucose lowering therapy(Sign 116)
62. Anecdotal evidence.• Information from three former students of GCU who are DSNs and have visited Malawi.• Women and their offspring are dying or suffering needlessly because gestational and other types of diabetes are not detected.
63. What we want to do.• Produce and distribute posters to raise awareness of diabetes.• Send a small team of experts to Malawi (pharmacist, physiologist, nutritionist, midwife and diabetes nurse specialist) to train and educate health workers on the problems caused by diabetes.• Note: we are in contact with (and have the support of) a medic who is in Malawi and is a diabetes expert.
64. What do we want to do? (continued)• Bring a number of interested health workers from Malawi to GCU so they can attend postgraduate education in diabetes care and management and attend relevant clinics in Scotland.• In due course these health workers can educate and train other health workers in Malawi.
65. What can you do?• Please contact Jane Nally (J.E.Nally@gcu.ac.uk) if you are able to help in gathering evidence or offer experience that can help us to apply for funding for this initiative.
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67. SMP Health Links Forum Tamara Mhura St Augustine Church 07th February, 2013 www.waverleycare.org
68. Who we are Voluntary organisationDelivering prevention, care &support services across Scotlandfor people living with HIV andHepatitis CIncludes an African Health Project www.waverleycare.org 90
69. What we do in Malawi Raise awareness Encourage Deliver maternal behavioural changehealth programmesDeliver campaigns Improve access to & Study circles health services www.waverleycare.org 91
70. Maternal HealthEarly attendance at antenatal clinicsUrge husbands to accompany wivesHIV testingFamily planningPMTCT www.waverleycare.org 92
72. ChallengesOnly 56% of women in MLW give birth at healthclinics; reduces to 50% in MzimbaMzimba has few clinics which are scattered &hard to reachUnfriendly/ unsympathetic health professionalsLack of facilities for guardiansHarmful cultural beliefs/practices www.waverleycare.org 94
73. Lament of a husband whose wife and baby son died in childbirth When I see a nurse “Me, when I see a nurse, I see cruelty. When I see a nurse I see a witch, www.waverleycare.org 95
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76. Input from MaSP Health Group MembersMs Grace Goti Tahuna Soko,Deputy College Principal, Holy Family College of NursingDr Alexander Chijuwa,District Health Officer, Phalombe District Health OfficeMr Steve Musopole,Principal Architect, Malawi PolytechnicDr Mulina NyirendaAdult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, (Ninewells Hospital),Mr Fyneck Kufeani,Electrical Engineer, Malawi Polytechnic, (UWS)Mr Webster Kadazi ChitsuloSecretary, Kuthandiza Osayenda Disability Outreach, (Global Concerns Trust)
77. Contributing factors toimproved maternal health inMalawi• Waiting antenatal wards, and an increase in number of rural maternal clinics• Community-based health: HSAs, community leaders, etc• Training of community midwives• Safe Motherhood Initiative• Up-skilling technicians where no registered nurse or midwife available• Training of traditional birth attendants
78. Main challenges towardsimproving MH in Malawi• Lack of resources: skilled personel, equipment, medication and finances• Inadequate infrastructure: access, facilities (electricity) and space• Socio-cultural attitudes: limited community participation, family planning• Information transfer and illiteracy
79. A Scottish contribution?• Infrastructure: building district hospitals, maternity units, training centres• Equipment: ambulances• Education: campaigns in schools and in the community• Training: training and retaining health professionals
80. Summary of recommendations from 2011 SMP Report:Malawi-led: Projects have to be developed in response to requests from Malawi. Teachingprogrammes should be adaptable to different cadres – doctors, nurses, midwives and clinicalofficers – and should support policies which foster good working relationships between thedifferent professional categories.Good stewardship: Making sure that funds are correctly used and accounted for.Sustainable: Training trainers is essential and ensuring local ownership of the programme. Ifequipment is available for sending make sure there is a need for it and that it can be servicedlocally.Coordinated: Good collaboration between groups in Scotland is important to avoid replication ofeffort but it is also important to establish that there is not duplication or overlap in Malawi.Capacity-building in Malawi: In addition to the benefit in terms of trainees working in their owncountry or region partnerships need to ensure that clinical experience gained was locallyrelevant.Exit strategy: Writing yourselves out of the script!Manage expectations: There is a need to clarify the commitment of Scottish staff going toMalawi on medium-term assignments (anxiety about losing out on National Insurance andsuperannuation payments).
81. Health Links Forum Action • Further discuss on challenge of per diem culture (SMP event?) Points • Promoting inter-disciplinary • MOU with NHS approaches • NHS administration of funding • Supporting leadership • Enabling Malawi-led ideas: management initiatives in Malawi working with MaSP to coordinate • Up-skilling efforts from Malawi • SMP training on financial management (Q3/Q4)• Discussion among SMP members on impact of devaluation on partner projects in Malawi • Important of education/relationship to maternal health
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